Transcript Case # 2 - American Academy of Pediatrics

The 3rd Annual
New York/New Jersey
Pediatric Board Review Course
General Pediatrics
Andrew D. Racine, M.D., Ph.D.
May 18, 2008
Outline
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Update on immunizations
Breastfeeding
Injury Prevention
Anticipatory Guidance
Dermatology review
Child Abuse
Update on Immunizations
Case #1
Question 1
A 12 year old girl presents to your office for a
regular checkup for school entry. She is a
recent immigrant from Mexico. Her mother
states that she does not have an immunization
record. She denies any significant past medical
history. There is no history of allergies.
Physical exam reveals no abnormalities.
Which immunizations would you give at this
time?
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A. Td, IPV, MMR, Varicella, Hep B, MCV4
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B. Td, IPV, MMR, Varicella, Hep B, MPSV4
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C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV
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D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4
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E. Tdap, IPV, MMR, Varicella, Hep B, MCV4, Hep
A, HPV
Pertussis Vaccine (Tdap)
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Two new tetanus toxoid, reduced diphtheria toxoid
and acellular pertussis vaccines were approved by the
FDA in 2005 and are now recommended for:
Adolescents aged 11-12 years who completed their
primary series of DTP/DTaP and have not received a
Td booster dose
Adolescents 13-18 years who missed the 11-12 year
Td/Tdap booster and completed their primary series
Adolescents who have not received
DTP/DTaP/Td/Tdap vaccination (or have no
documentation)
For wound management in adolescents who have not
received Tdap before
Meningococcal Vaccine (MCV4)
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Another change introduced into the
schedule in 2005 is the meningococcal
conjugate vaccine which is also
recommended in
Adolescents 11-12 years
Unvaccinated adolescents at school entry
College freshmen living in dormitories
Certain high risk groups
Hepatitis A Vaccine
In May of 2006 the ACIP broadened its
recommendations for the use of Hep A vaccine
to include all children between 1-2 years of age.
The use of Hep A vaccine is also recommended
for high risk groups including:
 Travelers to endemic areas, MSM, drug users,
persons with chronic liver disease, those with
clotting factor disorders
Human Papillomavirus Vaccine
Licensed in June 2006, the ACIP recommends
routine immunization of females from 9
years of age up to 26 years of age with a
three-dose series where the second and third
doses are administered at 2 months and 6
months after the first dose.
Based on the catch up schedule and the
requirements for a patient this age the patient
should receive:
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A. Td, IPV, MMR, Varicella, Hep B, MCV4
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B. Td, IPV, MMR, Varicella, Hep B, MPSV4
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C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV
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D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4
 E.
Tdap, IPV, MMR, Varicella, Hep B,
MCV4, HEP A, HPV
Pertussis
Pertussis remains endemic despite universal
immunization with DTaP. There are 2 peaks of
incidence. One is in children under the age of 6
months who are not vaccinated or incompletely
vaccinated. The other is in adolescent 11-18
years whose immunity has waned.
The morbidity in adolescents is significant. In
2004, 25,827 cases of pertussis were reported in
USA. 34% were in children 11-18 years.
Licensed Tdap Vaccines
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BOOSTRIX GlaxoSmithkline Biologicals
10-18 years of age, same t, d, p antigens
as INFANRIX but in smaller concentrations
ADACEL sanofi pasteur
11-64 years of age, same t, d, p antigens
as DAPTACEL but in smaller
concentrations
Side Effects of Tdap Vaccination
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Pain
Erythema
Swelling
Headache
Fatigue
Fever
GI events
Local Reactions
Systemic Reactions
Immediate Reactions including dizziness, syncope and
vasovagal reactions were reported with ADACEL
Case #1
Question 2
Before you give the Tdap vaccine to the
patient you ask your attending what is a
true contraindication for the vaccine.
Your attending responds that:
A. Temperature greater than 105 F within 48
hours of a previous DTP/DTaP
B. Collapse or shock like state within 48 hours
of a previous DTP/DTaP
C. History of encephalopathy within 7 days of
previous DTP/DTaP
D. Latex Allergy
E. Pregnancy
Contraindications of Tdap
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Anaphylaxis to any components of the
vaccine
History of encephalopathy (coma or
prolonged seizure) within 7 days of
administration of a pertussis vaccine that
cannot be attributed to a different cause
Precautions of Tdap
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History of an Arthus-type reaction following a
previous dose of tetanus- or diphtheriacontaining vaccine
Progressive neurological disorder, uncontrolled
epilepsy, or progressive encephalopathy
History of Guillain-Barre syndrome (GBS) within
6 weeks after a previous dose of tetanus toxoidcontaining vaccine
Moderate or severe acute illness
Not Contraindications
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Temperature > 105F within 48 hrs of DTP/DTaP
Collapse or shock-like state within 48 hrs of
DTP/DTaP
Persistent crying for 3 hrs or longer within 48
hrs of DTP/DTaP
Convulsions with or without fever within 3 days
of DTP/DTaP
History of entire or extensive limb swelling after
DTP/DTaP/Td
Stable neurological disorder
Not Contraindications
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Brachial neuritis
Latex allergy other than anaphylaxis-BOOSTRIX
single dose and ADACEL are latex free
Pregnancy and breastfeeding
Immunosuppression
Intercurrent minor illness
Antibiotic use
The only true contraindication of the
alternatives listed would be:
A. Temperature greater than 105 F within 48
hours of a previous DTP/DTaP
B. Collapse or shock like state within 48 hours
of a previous DTP/DTaP
C. History of encephalopathy within 7 days of
previous DTP/DTaP
D. Latex Allergy
E. Pregnancy
Meningococcal Disease
American Academy Of Pediatrics. Committee on Infectious Diseases. Prevention and Control of Meningococcal Disease:
Recommendations for Use of Meningococcal Vaccines in Pediatric Patients. Pediatrics. 2005:116(2):496-505.
Epidemiology of Meningococcemia
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Children < 1 year of age
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Adolescents 15-18 years of age
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College freshmen living in dormitories
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C5-C9 or C3 deficiency
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Functional asplenia
Licensed Meningococcal Vaccines
MENOIMUNE
Meningococcal polysaccharide vaccine MPSV4
Purified capsular polysaccharides A/C/Y/W-135
Licensed in 1981
MENACTRA
Meningococcal conjugate vaccine MCV4
Purified capsular polysaccharides A/C/Y/W-135
conjugated to diphtheria toxoid.
Licensed in 2005
Case #1
Question 3
Your attending asks you what are the
advantages of the new meningococcal
conjugate vaccine vs. the old
polysaccharide vaccine. You answer that
all of the following are true except:
A. The conjugate vaccine produces an antibody
response which lasts longer
B. The conjugate vaccine stimulates a booster
response
C. The conjugate vaccine promotes herd
immunity
D. The conjugate vaccine has less side effects
E. The conjugate vaccine reduces
nasopharyngeal carriage
MPSV4 vs. MCV4
MPSV4 antigens induce a T cell independent antibody
response. As a result there is
 A short lived response
 No anamnestic or booster response with
subsequent challenge
 No reduction in nasopharyngeal carriage
MCV4 antigens are conjugated to diphtheria toxoid so
they induce a T cell dependent response resulting in
 A long lasting memory
 Booster response and
 eradication of nasopharyngeal carriage which
contributes to herd immunity.
Advantages of MCV include all of the following
except:
A. The conjugate vaccine produces an antibody
response which lasts longer
B. The conjugate vaccine stimulates a booster
response
C. The conjugate vaccine promotes herd
immunity
D. The conjugate vaccine has less side effects
E. The conjugate vaccine reduces
nasopharyngeal carriage
MCV4
Side effects include:
Erythema, swelling and induration
Guillain-Barre – 17 reported cases from
March 2005 – September 2006. GBS
incidence estimated at 0.20 per 100,000
person months after vaccine compared to
0.11 per 100,000 person months among
11-19 year olds generally.
Human Papillomavirus
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The most common sexually transmitted infection
in the United States (6.2 million new cases
annually).
HPVs are non-enveloped double stranded DNA
viruses of over 100 types including several
(16,18,31,33,35, and others) detected in 99% of
cervical cancer cases.
Risk of HPV associated with number of sexual
partners, partner sexual behavior, and immune
status.
Human Papillomavirus
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Most infections are transient,
asymptomatic and clear within 1-2 years
Of the 6.2 million new cases per year,
about 74% occur in women 15-24
Acquisition occurs soon after sexual debut
Prevalence of HPV 16 may be as high as
40%
Consistent condom use may help prevent
acquisition
HPV Vaccine
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Quadravalent HPV vaccine (Gardasil®) targets
HPV types 6, 11, 16 and 18
HPV types 16 and 18 cause approximately 70%
of cervical cancers and types 6 and 11 cause
approximately 90% of genital warts
Administered in 3 doses with second and third
doses given 2 and 6 months after the first dose
Combined protocols indicate an efficacy of 98100% in the prevention of CIN 2/3, AIS or
genital warts caused by HPV 6, 11, 16 and 18.
Case #1
Question 4
You explain to your attending your intention
to administer the Gardasil® vaccine and he
responds, “Are you nuts? That vaccine
costs a gazillion dollars!! What are you a
Merck shareholder or something?” You
calmly reply that:
A. The vaccine only costs $50 per dose
B. The treatment of genital warts and
cervical cancer costs more than $8 billion a
year in the U.S.
C. Depending upon how long you assume
immunity lasts and what percent of girls get
the vaccine, immunizing all 12 year old girls
will cost only $3,000 to $25,000 per QALY.
D. Vaccinating will save the future costs of
having to screen for cervical cancer in these
patients
HPV Costs and Benefits
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Management of warts and cervical cancer costs
about $4 billion per year in the U.S.
Vaccine for Children’s program (VFC) will cover
costs of Gardasil for eligible patients
Several cost/benefit analyses estimate the cost
of a QALY to be between $3,000 and $25,000
depending upon underlying assumptions
Factors to consider: duration of vaccine
protection, duration of natural immunity,
frequency of cancer screening, vaccine coverage
A. The vaccine only costs $50 per dose
B. The treatment of genital warts and
cervical cancer costs more than $8 billion a
year in the U.S.
C. Depending upon how long you assume
immunity lasts and what percent of girls get
the vaccine, immunizing all 12 year old girls
will cost only $3,000 to $25,000 per QALY.
D. Vaccinating will save the future costs of
having to screen for cervical cancer in these
patients
Case #1
Question 5
You ask your 12 year old patient to return in
4 weeks to continue the catch up schedule
of vaccination you started.
At that visit you will administer:
A. Td,IPV,MMR,Hep B
B. Td,IPV,MMR,Varicella,Hep B
C. Tdap,IPV,MMR,Hep B,MCV4
D. Tdap,IPV,MMR,Varicella,Hep B
E. Tdap,IPV,MMR,Varicella,Hep B,MCV4
Catch-up Schedule
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Tdap is licensed for only one dose.
According to the AAP, the patient in this case
should receive 3 tetanus/diphtheria toxoid
vaccines and only one of them should also
contain pertussis, preferably the first dose.
Varicella- Two doses are now recommended.
A 2nd dose is given in 4 weeks for those over
13 and in 3 months for those less than 13.
MCV4 only one dose is required.
Return Visit should include:
A. Td,IPV,MMR,Hep B
B. Td,IPV,MMR,Varicella,Hep B
C. Tdap,IPV,MMR,Hep B,MCV4
D. Tdap,IPV,MMR,Varicella,Hep B
E. Tdap,IPV,MMR,Varicella,Hep B,MCV4
Hepatitis A
Vaqta and Havrix are both licensed for
children 1 year of age and older and they
are now recommended as part of the
routine immunization schedule to be given
to all children at the age of 1 year.
Children who are not vaccinated by 2
years should be vaccinated at subsequent
visits. 2 doses are recommended 6
months apart.
Influenza
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Influenza vaccine risk factors now include
children with compromised respiratory function
or handling of respiratory secretions and also
children that have an increased risk of
aspiration.
In July 2007, ACIP issued a recommendation
expanding routine influenza vaccination to
children 6 – 59 months and their household
contacts. Previously unvaccinated children
should receive 2 doses this vaccine.
Rotavirus
Rotavirus is the leading cause of severe gastroenteritis
worldwide resulting in more than 500,000 deaths/year.
In the USA it is a major disease burden with 3.2 million
episodes of diarrhea, 60,000 hospitalizations and 2060 deaths /year.
Additional problems include
 Shedding of the virus before sxs develop and up to 21
days after onset of the disease
 Children developing insufficient immunity after one
infection and therefore experiencing it more than once
 Major cause of day-care center acquired
gastroenteritis
Rotavirus vaccines
All rotavirus vaccines are oral, live attenuated,
containing glycoprotein (VP7) and protease-cleaved
proteins (VP4) of Group A rotavirus, the most
prevalent type found in humans.
ROTASHIELD –licensed in 1998, tetravalent rhesushuman reassortment, withdrawn from the market due
to cases of intussusception.
ROTATEQ – FDA approved in 2006, pentavalent bovinehuman reassortment, no intussusception reported in
large trial of 70,000 doses.
ROTARIX – licensed in 30 countries but not in USA yet,
divalent human vaccine, also well tolerated.
Breastfeeding
Case # 1
A female infant presents for her two week
check-up. She was born after a 38 week
uncomplicated pregnancy via spontaneous
vaginal delivery at a birth weight of 3 kg.
Her mother is breastfeeding and asks
whether breast milk alone is sufficient for
her baby. What advice should you give
her?
True or False?
1. The baby should receive oral iron supplements
for the first 6 months of life.
2. The baby does not need vitamin K after birth so
long as the mother is taking oral Vitamin K.
3. Starting before 2 months of age the baby will
need 200 IU of vitamin D daily while she is
exclusively breastfed.
Question # 1
False
Iron
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Iron stores at birth are proportional to birth
weight or size.
Iron stores for term infants are sufficient to
meet needs for the first 4-6 months of life.
Breast milk contains <0.1 mg/100cc of iron
but it is in a highly bio-available form (50% of
it is absorbed compared to 4% of iron in ironfortified formulas).
Infants’ adequate intake of iron is
approximately 0.27 mg/day for the first 4-6
months of life.
Question # 2
False
Vitamin K
Vitamin K is a fat soluble vitamin necessary for the
posttranslational carboxylation of glutamic acid
residues of coagulation proteins Factors II, VII,
IX and X.
lpi.oregonstate.edu/infocenter/vitamins/vitamink/kcycle.html
Vitamin K
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Breast milk has inadequate amounts of
vitamin K to satisfy infant requirements.
All breastfed infants should receive 0.5 1.0 mg of vitamin K IM after the first
feeding and within the first 6 hrs of life.
Oral vitamin K may not provide the
stores necessary to prevent
hemorrhage in later infancy and is not
recommended at this time.
Question # 3
True
Vitamin D
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Vitamin D (calciferol) is available from
certain dietary sources and can be
synthesized in skin upon exposure to UV
light.
Adequate intake of vitamin D for infants is
200 IU per day.
Vitamin D content of human milk is low
(22 IU/L).
Vitamin D
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Breastfed infants should receive
supplements of 200 IU of vitamin D per
day so long as the daily consumption of
vitamin D-fortified formula or milk is below
500 ml.
The recommended routine use of
sunscreen in infancy decreases vitamin D
production in skin.
More on Breastfeeding
Compared to the weight gain of formula fed
infants in the first year of life, the weight gain
of breast fed infants:
A.
Is less rapid during the first 3-4 months but
then catches up
B.
Is more rapid during the first 3-4 months but
then slows down
C.
Generally results in a slightly heavier infant by
12 months of age
D.
Does not differ at all
More on Breastfeeding
Compared to the weight gain of formula fed
infants in the first year of life, the weight
gain of breast fed infants:
A. Is less rapid during the first 3-4 months but
then catches up
B. Is more rapid during the first 3-4 months
but then slows down
C. Generally results in a slightly heavier infant
by 12 months of age
D. Does not differ at all
More on Breastfeeding
Breast fed infants tend to gain more weight
than do formula fed infants in the first 3-4
months of life.
It is acceptable for their weight gain to cross
one or two percentiles downward in the
period after 4 months so long as they
maintain their length and head
circumference.
More on Breastfeeding
By the end of the first year of life, breast fed
infants who had solids introduced at 4-6
months of age tend to be slightly leaner
than formula fed infants.
Term infants require between 100 to 120
kcal/kg per day in order to grow.
Injury Prevention
Injury Prevention
A 6 month old boy is at your office with his
father for a routine health care
maintenance visit. In discussing injury
prevention for his infant, the father wants
to know what he should be most
concerned about with respect to his
infant’s safety. What should you tell him?
Leading Causes of Death by Age
Group - 2001
1
2
3
< 1 yr
1-4 yrs
5-9 yrs
10-14 yrs
Congenital
Anomalies
5,513
Short
Gestation
4,410
SIDS
2,234
Unintentional
Injury
1,714
Congenital
Anomalies
557
Malignant
Neoplasms
420
Unintentional
Injury
1,283
Malignant
Neoplasms
493
Congenital
anomalies
182
Unintentional
Injury
1,553
Malignant
Neoplasms
515
Suicide
272
Leading Causes of Injury Deaths
by Age Group 2001
100%
80%
Other
Firearms
Burn
Drown
Motor Veh
60%
40%
20%
0%
1-4 Years
5-9 Years
10-14 Yrs
Deaths Due to Injury
in Childhood
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SIDS is the leading preventable cause of
death in children less than 1 year of age.
Unintentional injury is the leading cause of
death in children from 1 to 15 years of age.
Motor vehicle incidents, drowning and deaths
from burns taken together account for over
75% of all deaths from injury in children
between 1 and 15 years of age.
Motor Vehicle Injury Prevention
When counseling a parent with respect to infant car
seats, all of the following are true except:
A.
Children should face the rear of the vehicle until
they are at least 1 year of age or weigh at least
20 lbs.
B.
Convertible safety seats positioned upright and
facing forward should be used for children
beyond 1 year and 20 lbs until they reach 40 lbs.
C.
A rear facing car safety seat must not be placed
in the front passenger seat of any vehicle with
an air bag on the front passenger side.
Motor Vehicle Injury Prevention
Answer A: Children must weigh 20 lbs and be
at least 1 year of age before sitting in a
forward facing car seat. Many infants reach
20 lbs before their first birthday but should not
be turned to face forward
before that time.
Motor Vehicle Injury Prevention
Convertible seats are the safest for children
after they reach 1 year and 20 lbs until they
are 40 lbs and can use booster seats.
Convertible
Car Seat
(Up to 40 lbs)
Booster
Car Seat
(More than
35-40 lbs)
Motor Vehicle Injury Prevention
No rear facing seats should be placed in the
front passenger seat of a car equipped
with air bags; and any child less than 13
should preferentially sit in the rear seat to
avoid injury from inflating air bags.
Drowning Injury
The father of that 6 month old infant also
has a 4 year old boy at home. When
counseling him about the epidemiology of
childhood drowning, a TRUE statement is:
A. Drowning is the leading cause of
death due to injury
B. For every one drowning victim there
are 5 near drownings
C. Pool alarms have eliminated the need
for fencing
D. Residential pools are the most
common drowning sites
E. The ratio of male-to-female drowning
deaths is 1:1
Drowning Injury
Residential pools are the most common site of
drowning for children younger than 5. Infants
drown in bathtubs most often and adolescents in
fresh water lakes and rivers.
Drowning is the 2nd leading cause of death in this
age group (remember earlier) with peak
incidence in the summer months and highest
rates in the west and the south.
Drowning Injury
Four sided fences 5 ft high with self-closing selflocking gates are the most effective enclosures
for residential pools.
Pool alarms, pool covers, swimming lessons for
young children and floatation devices are not as
effective as proper enclosures in preventing
drowning deaths.
Male to female ratio is 3:1 and 50% of submersion
victims are declared dead at the site (drowning
to near drowning ratio of 1:1).
A. Drowning is the leading cause of
death due to injury
B. For every one drowning victim there
are 5 near drownings
C. Pool alarms have eliminated the need
for fencing
D. Residential pools are the most
common drowning sites
E. The ratio of male-to-female drowning
deaths is 1:1
Injury Prevention: Burns
You are approaching the end of a health
care maintenance visit for a 2 year old girl.
The mother explains that the family
recently moved into a private house
having lived previously in an apartment.
What four concrete pieces of advice can
you give her about how she might make
her new home safe from the standpoint of
preventing burn injuries to her toddler?
Injury Prevention: Burns
1. Don’t smoke in the home.
Home fires cause three fourths of all fire
deaths and children below the age of 5
are at highest risk.
Adults who smoke carelessly or who fall
asleep while smoking are responsible for
the largest percentage of home fires that
kill or injure children.
Injury Prevention: Burns
2. Install smoke detectors on each floor in
the house and test them every 6 months.
Smoke detectors provide the best protection should
a home fire begin since: a) most fires start in the
early morning hours; b) most fires burn for a
long time before discovery; and c) deaths are
usually due to CO poisoning so early alerts can
help prevent injury and death.
Injury Prevention: Burns
3. Prepare emergency escape plans for use
in the event of a fire.
Even children as young as 3 can be taught how to
safely get out of the house in the event of a
fire. If fire extinguishers are available in the
home (and they should be) children should
always be taught to leave the house rather than
try to put out a fire themselves.
Injury Prevention: Burns
4. Set hot water heaters at no higher than
120o F.
Tap water at 160o F can produce a fullthickness scald burn in less than 1
second. At 120o F the scalding time is
increased to between 2 and 10 minutes.
Anticipatory Guidance Potpourri
A six month old breast fed male infant is at your
office for a well child check-up. He has been
previously well and on exam babbles, reaches
for your stethoscope and pulls to a sitting
position without head lag. He can also:
1.
2.
3.
4.
5.
Finger feed himself
Imitate sounds
Pull to stand
Transfer objects from one hand to the other
Use a scissors grasp to obtain a piece of cereal
Anticipatory Guidance
Potpourri
Correct answer is 4, transfer objects.
As part of his normal development this infant
probably began to hold a rattle briefly at 2
months, reached for objects and and lifted himself
onto extended elbows at 4 months. He probably
also began to roll over at 4 months and could roll
both ways by 6 months. He likely began to coo at
2 months, to laugh out loud at 4 months, and to
begin to babble at 6 months. Pulling to stand
usually begins around 8 months. Finger feeding
and imitating sounds usually starts at 9 months.
Anticipatory Guidance
Potpourri
You are seeing a set of parents with their 8 year
old boy for a health care maintenance visit. The
mother asks you whether allowing her son to
watch TV when he comes home from school is a
bad idea.
The MOST accurate statement you can make to
her about the influence of television viewing on
children is:
TV Viewing
A. Most adolescents have difficulty discriminating
between what they see on TV and what is real.
B. Nearly 2/3 of all programming includes violence
and children’s programming contains the most
violence.
C. 50% of 2-7 year olds have a TV in their room.
D. A majority of parents report that they always
watch TV with their children to monitor the
content of what is seen.
TV Viewing
Although young children and adolescents are
vulnerable to the messages conveyed on
television, it is predominantly younger children
who cannot discriminate between what is real
and what they see on TV. In a random survey of
parents with children from kindergarten through
6th grade published in 1996, 37% reported that
their child had been frightened or upset by a TV
program seen during the preceding year.
Cantor J, Nathanson AI. Children’s fright reactions to television news. J Commun. 1996;46: 139-152.
TV Viewing
About one third of parents of 2-7 year olds
report that their children have a television
in their room.
Less than half of all parents state that they
always watch television with their children
to monitor the content of what is being
seen.
TV Viewing
A recently completed 3 year National Television
Violence Study reported that:
 Nearly 2/3 of all programming contains
violence;
 That children’s shows contain the most
violence;
 That portrayals of violence are usually
glamorized; and
 Perpetrators often go unpunished.
Federman J. ed. National Television Violence Study Vol 3. Thousand Oaks, CA: Sage; 1998.
TV Viewing
A. Most adolescents have difficulty
discriminating between what they see on
TV and what is real
B. Nearly 2/3 of all programming includes
violence and children’s programming
contains the most violence
C. 50% of 2-7 year olds have a TV in their
room
D. A majority of parents report that they
always watch TV with their children to
monitor the content of what is seen
Dermatology
Case # 1
A 2 month old boy experiences the
onset of a salmon-colored confluent scaly
rash on his cheeks, neck, groin and axillae.
The mother points out an erythematous
patch behind the right ear. There is no
history of fever or other systemic symptoms.
The patient seems otherwise well and is not
uncomfortable with the rash. There is no
involvement of his nails.
dermatlas.com/derm/
The rash is consistent with
A. Atopic Dermatitis
B. Candidal Dermatitis
C. Seborrheic Dermatitis
D. Contact Dermatitis
E. Psoriasis
C. Seborrheic Dermatitis
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Etiology – unknown
Epidemiology – seen during infancy and in
adolescence
Clinical – symmetric distribution in areas of high
concentration of sebaceous glands (face, scalp and
intertriginous areas such as neck, axilla, groin, post
auricular). Salmon colored and scaly. Non pruritic.
Treatment – Skin – topical steroids
Scalp – oil/comb or antiseborrheic shampoo
Complications – Secondary infection
Post inflammatory pigmentary
changes
dermatlas.med.jhmi.edu
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
Atopic Dermatitis
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Etiology – Unknown. Interplay of genetics and
environment. Associated with atopy. More than
50% develop asthma/allergic rhinitis.
Epidemiology – 10-15% of children, with
rapidly increasing prevalence.
Pathogenesis – Keratinocytes induce T cells to
produce decreased g interferon (a T2 inhibitor)
thus contributing to eosinophilia and IgE.
Clinical – Vicious cycle which begins with
predisposition to dry skin – pruritis - scratching
- more dryness and erythematous weeping
crusted rash with indistinct border.
Distribution varies with age:
Infantile - Starts on cheeks and spreads to
neck/wrists/hands/abdomen/extensor surfaces.
Diaper area often spared.
Childhood – Extensor lesions now become
flexural. Greater tendency for chronicity.
Adolescent – Also includes dorsal hands, feet
and between fingers and toes. May also
involve eyelids, infra auricular fold and vulva.
Lichenification – thickened, hyperpigmented skin
Atopic pleats – extra groove on lower eyelid
Pallor around nose, mouth and ears
Treatment – “Break vicious cycle” lubrication,
humidifiers, mild soaps, soft cotton clothing, anti
pruritics.
 Food elimination – May be considered in children
under 2 yrs. since it is associated in 40% of cases.
 Topical Steroids – Start with low potency.
 Immune modulators –The FDA after reviewing their
safety has issued a warning that the use of calcineurin
inhibitors may be associated with an increased risk of
cancer. For refractory mod to severe cases.
 Tar, phototherapy and systemic treatment with
glucocorticoids, cyclosporine and interferon reserved
for severe cases.
Complications – Secondary infection due to altered cell
immunity (MRSA, eczema herpeticum).
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
Psoriasis
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Etiology – Unknown. Associated with certain
HLA types. Multifactorial inheritance.
Epidemiology – Incidence 1-3%. Onset before
age 20 in 37% of cases. In childhood F:M ratio
2:1. Adults 1:1.
Clinical – Round, erythematous, well
marginated patches covered by a grayish or
silvery white scale. Individual small lesions
coalesce to form patches. Distribution – scalp,
extensor surfaces, lumbosacral, anogenital
regions. Sometimes flexural.
Special Features
 Auspitz sign – removal of scale results in fine
punctate bleeding points.
 Koebner phenomenon – skin lesions that occur
at the site of local injury
 Guttate psoriasis – round or oval lesions appear
suddenly over a large part of the body after a
URI, with strep or withdrawal of steroids.
 Pityriasis amianteca – psoriasis on the scalp firmly adherent crusts somewhat resistant to tx.
 Nail involvement – Pitting, discoloration,
subungal hyperkeratosis, onycholysis.
Pathogenesis – Marked increase in epidermal cell
turnover.
Treatment – Lubrication, avoid scratching.
 Steroids – use least potent topical that’s
effective
 Vit D Analogs – calcipotriene stings, takes long
to work
 Topical Retinoids – syst tox in large quantity
 Tar +/- UV light or PUVA (UV + psoralens)
 Systemic methotrexate, oral retinoids,
cyclosporine.
Complications – Psoriatic arthritis. No
relationship between severity of cutaneous
disease and the development of joint disease.
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
Contact Dermatitis – non allergic
Irritant Contact Dermatitis – results from direct
contact with caustic agents which include
soaps, bleaches, detergents, solvents, bubble
baths, saliva, urine, feces, etc. resulting in
changes in the skin which follow the
distribution of the contact. Classical example is
diaper dermatitis – Fecal enzymes are activated
by alkaline urea in the urine. Rash is
erythematous, scaly, well demarcated and
distributed along the convex surfaces of the
perineum, sparing intertriginous areas.
Treatment includes frequent diaper changes,
gentle cleaning and barrier pastes.
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
Contact Dermatitis - allergic
Etiology – Type IV delayed type hypersensitivity
reaction. Agents include poison ivy, oak and sumac,
nickel, rubber, glue, dye, neomycin, topical anesthetics
and antihistamines, cosmetics.
Clinical – Erythema, intense pruritis, vesiculation,
crusting and scaling with distribution following the
pattern of sensitization.
Initial reaction – 8-12 hours following exposure.
Subsequent reaction – 7 – 10 days following exposure.
Treatment – avoidance, washing skin immediately after
contact, steroids topical and oral, antihistamines.
Case #2
The following painful lesion developed in a
5 year old boy who was playing in his back
yard where there were a lot of
mosquitoes.
www.atlas-dermato.org
The lesion is
A. Impetigo
B. Folliculitis
C. Furuncle
D. Ecthyma
E. Erysipelas
D. Ecthyma
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Etiology – beta hemolytic strep, occasionally
staph and pseudomonas.
Epidemiology – Poor hygiene, malnutrition,
trauma, insect bites and other pruritic lesions.
Clinical – Vesicle with erythematous base and
crusting erodes into the skin forming an ulcer
with elevated margins. Lesions are painful,
slow growing and chronic. Commonly found in
the lower extremities and the buttocks.
Treatment – warm compresses, removal of
crusts, systemic antibiotics
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
Impetigo
Etiology – beta hemolytic strep and staph
 Epidemiology – any age but more common in
the young, in exposed areas (non bullous), in
traumatized areas of skin (bullous)
 Clinical – Non bullous – erythematous macules
-> thin roofed vesicles surrounded by a red
base –> rupture and release yellow fluid –>
drying with formation of honey colored crust.
Bullous – superficial blisters that rupture
and leave an erythematous, denuded base.
Autoinoculation contributes to spread.
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Treatment –
With localized lesions topical mupirocin.
With disseminated lesions systemic treatment
with diclox, augmentin, cephalexin,
clindamycin.
Complications – Beta strep infections can result
in acute glomerulonephritis and scarlet fever.
In addition, both organisms can contribute to
the development of osteomyelitis, arthritis,
pneumonia, sepsis, cellulitis, lymphangitis.
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
Folliculitis
Superficial or deep infection of hair follicles
 Etiology – S. aureus. Occasionally strep, proteus,
pseudomonas.
 Epidemiology – Induced by agents that obstruct
pilosebacious glands such as oils, tars, occlusive
dressings. Atopic dermatitis and seborrhea predispose
as well as poor hygiene and excess sweating. Shaving
can cause sycosis barbae, a deeper form of folliculitis.
Hot tub dermatitis occurs in areas covered by the
bathing suit and is caused by pseudomonas 8-12 hrs
after exposure.
 Clinical – yellow pustule surrounded by red areola
surrounding a hair shaft. Distributed anywhere on the
body where there is hair.
 Treatment – avoid offending agent, gentle cleansing,
topical antibiotics.
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
Furuncle
Develops from preceding folliculitis which extended more
deeply into the skin or from trauma.
Etiology – Staph aureus Group I and II.
Clinical – red, tender, well circumscribed nodule which
enlarges and then becomes boggy and fluctuant. If
untreated it will suppurate and release purulent
discharge. Healing results in scar formation.
Treatment – systemic antibiotics and incision and
drainage.
Complications – carbuncles which are aggregates of
interconnected furuncles that drain at multiple points
on the cutaneous surface. They present with systemic
symptoms such as fever, malaise and prostration.
Seen more commonly with obesity, diabetes and
immunosuppression.
dermatlas.med.jhmi.edu
forlag.fadl.dk
Erysipelas
Cellulitis with marked lymphatic vessel involvement due
to Group A beta hemolytic streptococci.
Epidemiology – direct inoculation or hematogenous
spread.
Clinical – Abrupt onset of systemic symptoms followed
by an area of erythema which enlarges to reveal a
tense, hot, painful, shiny, brawny infiltrated plaque
with a distinct and well marginated border. Most
commonly on the face and the scalp but can be
anywhere.
Treatment – Penicillin. If allergic then erythromycin or
clindamycin. With penicillin resistance nafcillin,
oxacillin, augmentin, cephalothin, cefazolin
Complications – Patients my become bacteremic,
especially infants.
Case #3
A 12 year old female patient is diagnosed
with UTI. Two days after starting
treatment with bactrim she experiences
the acute onset of the following rash:
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
The rash is most likely to be
A. Fixed Drug Eruption
B. PLEVA
C. Exanthematous Drug Eruption
D. Urticaria
E. Erythema Multiforme
E. Erythema Multiforme
Mucocutaneous hypersensitivity syndrome
 Etiology – Viruses (most commonly herpes
simplex), bacteria (including mycoplasma),
protozoa, fungi, TB, foods, immunizations,
sunlight, malignancy, radiotherapy, IBD,
Polyarteritis Nodosa, Sarcoidosis, Graft vs. Host
disease.
Many drugs can cause EM including sulfa,
penicillin, tetracycline, anticonvulsants,
allopurinol, barbiturates, salicylates, NSAIDs,
isoniazid, captopril, etoposide.
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Clinical – Acute onset of a fixed, symmetrical
eruption consisting of erythematous macules,
papules, vesicles or bullae with predilection for
palms, soles, dorsi of hands and feet, extensor
surface of arms and legs. May extend later to
trunk, face and neck. The hallmark lesion of
EM is the target – an erythematous plaque with
central clearing and a dusky center.
If an enanthem is present it involves oral
lesions only.
Treatment – Supportive.
Stevens – Johnson
Severe form of EM.
Characterized by an
abrupt prodrome, same
eruption as EM and
involvement of at least
2 mucous membranes.
Treatment is supportive
and morbidity and
mortality are significant.
dermatlas.med.jhmi.edu
Pityriasis Lichenoides et
Varioliformis Acuta
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Also known as Mucha Habermann’s Disease
Thought to result from immune
dysregulation prompted by exposure to viral,
bacterial or other environmental antigen
Recurrent crops of red papules 2-4 mm with
central crustingb (looks like chickenpox)
May treat with oral erythromycin for 1 –2
months
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
Urticaria
Experienced by 20%, but most of the time the
etiology is unknown.
Allergic causes
 Antibiotics –Penicillins/Cephalosporins/Sulfa
Urticaria can occur during or soon after course.
 Bee stings
 Seasonal and contact allergens
 Food – Infants – eggs/milk –may outgrow.
Older children – peanuts/sesame/shellfish/fish --do not outgrow.
Non-allergic Causes
 Cholinergic – heat, exertion, sweating & stress induce
acetylcholine which in turn induces histamine release
and urticaria. Starts in adolescence.
 Aquagenic – contact with water or perspiration.
 Solar – with minimal exposure to sunlight.
 Cold – inherited (mild), acquired (severe)
 Viral – EBM, Hep C, Herpes, Coxsackie
 Pressure – tight clothes. Onset 4-6 hrs after pressure.
 Vibratory – working with drills or jackhammers.
 Papular – at the site of insect bites.
 Histamine induced –product induces histamine release
in non allergic patient (IVP dye, azo dye)
Characteristic rash is composed of erythematous
wheals that are highly variable, rapidly
changing and transient with individual lesions
lasting less than 24-48 hours. Intensely
pruritic. It may be associated with
angioedema.
Acute <6 weeks, causes can often be found.
Chronic > 6 weeks, commonly unknown etiology.
May be an important sign of systemic disease
including malignancy, CV, autoimmune disease.
 Treatment – avoidance, antihistamines (H1
+H2 may work better than H1), steroids,
cyproheptadine (cold), leukotriene inhibitors
(together with H1).
Vanderhooft. Contemporary Pediatrics. 1998. Vol 15(5):118-137
Exanthematous Drug Eruption
This is the most common drug reaction and
is responsible for 50% of all drug
reactions.
It consists of erythematous macules and
papules which begin on the trunk, then
spread to the face and extremities and
may include palms and soles. It is pruritic
and not associated with fever.
It resembles a viral exanthem and must be
carefully distinguished.
Child Abuse
Case #4
The parents of a 9 month old baby
girl who is new to your practice bring
her for a regular checkup. There are
no complaints. Physical exam reveals
the following lesion:
dermatlas.com/derm/
The following risks factors may
indicate child abuse except:
A. Patient is less than 3 years of age
B. There is a history of spousal abuse
C. Father is an alcoholic
D. Mother did not breastfeed the child
E. The child is a foster child
D. Mother did not breastfeed the child
Risk factors for Child Abuse – Parental
 Past history of abuse or family violence
 Inability to cope, lack of support, attachment issues
 Closely spaced pregnancies, financial problems
 Alcoholism, addiction, psychosis, depression
 Young parental age, single parent
Risk factors for Child Abuse – Child
 Child is less than 3 years of age
 Twin, prematurity
 Chronic illness, mental retardation, learning disability
 Foster or adopted child
Child abuse – Physical signs
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Bruises, burns, bites, blunt-instrument marks
Fractures – bucket handle, posterior rib
fractures, multiple fractures at different stages
of healing
Intracranial hemorrhages
Retinal hemorrhages
Duodenal hematomas, lacerations of liver and
spleen, mesenteric tears
Oral lacerations
Failure to thrive
Multiple posterior rib fractures
Bucket handle fracture
aafp.org/afp/ 20000515/3057_f7.jpg